- Email: [email protected]
Female voluntary surgical contraception via minilaparotomy under local anesthesia
111
1~ J Gynecof Obsfet, 1992, 39: 11l-l 16 International Federation of Gynecology and Obstetrics
Female voluntary surgical under local anesthesia
contraception
via minilaparotomy
K.E. Jack” and C.R. Chaob ‘School of Public Health and bDepartment of Obstetrics and Gynecology, Columbia University, New York, NY (USA)
(Received February 13th, 1992) (Revised and accepted March 3Oth, 1992)
Abstract Objective: To examine changes in prevalence and acceptance of sterilization methods in a developing country from 1986 to 1990. Method: Data from 5182 voluntary female sterilizations performed at 52 service sites in Nigeria were retrospectively reviewed for sterilization method, anesthesia technique, demographic factors, and patient acceptance. Results: The annual number of sterilization procedures increased dramatically over this period from 688 in 1986 to 191I in 1989. Overall, 74.3% of the procedures were performed by minilaparotomy under local anesthesia (ML/LA), 6% by laparascopy/general anesthesia, and 19.7% by laparatomy/general anesthesia. ML/LA was found to be a very safe method, with a complication rate of 1.4% 98.6% of ML/LA patients expressed complete satisfaction with the procedure. Conclusion: Female sterilization increased in acceptance in Nigeria over the period 1986-1990 concomitant with the increased use of ML/LA. This approach is safe, costeffective, and appropriate for the developing world. Keywords: Surgical contraception; Minilaparotomy; Local-anesthesia; Developing world.
used method of contraception in the world, from an estimated 15 million in 1979 to over 100 million by 1985 [6,9]. Each year about 10 million women throughout the world choose to be sterilized. Sterilization prevalence is high in the developed countries, ranging from 30 to 40% in Canada, USA, and Europe; however, the incidence of voluntary sterilization in Africa is the lowest in the world - less than 1% in most African countries [8]. Nevertheless, in general, the incidence of sterilization in the developing world is rising in many countries and nowhere is it declining. Statistics on sterilization in Nigeria are sparse and detailed data of trends in voluntary female sterilization has not been previously studied. It is important from the public health standpoint to determine what factors unique to African settings might improve the acceptance of voluntary sterilization. We present service statistics of female sterilization in a nationwide voluntary surgical contraception (VSC) program between 1986 and 1990 to summarize the trends and the correlates of VSC in Nigeria. These data suggest that the route of anesthesia and surgical approach may be important determinants in female sterilization acceptance. Materials and methods
Introduction Over the past two decades, surgical sterilization has become the most frequently 0020-7292/92/$05.00 0 1992 International
Service statistics of female sterilizations from 52 service sites of a nationwide voluntary surgical contraception program supArticle
Federation of Gynecology and Obstetrics
112
Jack and Chao
ported by the Association for Voluntary Surgical Contraception (AVSC) between 1986 and 1990. For this program, Nigeria is divided into four zones. Four large teaching hospitals served as zonal centers with the additional responsibility to supervise and coordinate the other urban and rural sites in their zones. The northwest zone has 6 sites; the northeast zone (12 sites) has Jos University Teaching Hospital (JUTH) as the zonal center; the southeast zone has 9 sites and the southwest (25 sites) has University College Hospital (UCH) Ibadan, as the zonal center. AVSC requires these centers to report accurate quarterly statistics. JUTH, an active representative zonal center and service site, was visited and 141 client case records from January 1989 to December 1989 were studied to ascertain the correlates of voluntary female sterilization in Nigeria. The following variables were investigated: age of clients at sterilization, marital status, number of living children (sons and daughters), the primary reasons for sterilization and who made the decision. Other factors studied included the surgical approach employed, the type of anesthesia, the associated surgical complications, the postoperative hospital stay, the postoperative complications encountered and the client satisfaction as obtained by the client’s response to the question of whether she would recommend surgical contraception to others. The general trend of female voluntary sterilization was traced and the choice of minilaparotomy under local anasthesia vis-a-vis laparoscopic sterilization was studied. Description of minilaparotomy anesthesia (ML/LA)
under local
A detailed description of standard ML/LA procedure for the program is given elsewhere [lo]. In brief, the procedures are performed in simple ambulatory surgical theaters by obstetricians/gynecologists or nonspecialist doctors appropriately trained for ML/LA in training programs supported by AVSC. The patient is premeditated with 0.6 mg atropine intramuscularly. She is prepared and draped Int J Gynecol Obsrer 39
in the dorso-lithotomy position. With a speculum in the vagina, the cervix is grasped with a tenaculum. After adequate dilatation, a uterine manipulator is inserted to lift the uterus and manipulate the uterus to either side in order to reach the fallopian tubes. Immediately after the pelvic manipulation, the suprapubic (in cases of interval procedure) or infra umbilical tissues (in cases of immediate postpartum sterilization) are infiltrated with 1% xylocaine (lo-20 cc maximum) using a 1.5-inch 25-gauge hypodermic needle through a single puncture at the operation site. Each layer is infiltrated before incision. Usually a 2-5-cm long transverse incision is made. After the abdomen is opened, the fallopian tubes are hooked out and anesthestized with 5 cc of 1% xylocaine. Tubal occlusion is carried out usually using the Pomeroy technique of ligation and excision, but sometimes clips are applied. After tubal occlusion, the peritoneum may be closed. The skin closure is performed with interrupted nonabsorbable sutures or absorbable subcuticular sutures and covered with ordinary sterile dry dressing. The patient is then transferred to the recovery room where she is observed for vital signs until she is stable. After this period she is discharged home with mild analgesics. The patient is scheduled for a follow-up visit after 7 days. RMItS
From January 1986 through December 1989, there were a total of 5182 cases of female surgical sterilization reported to AVSC in Nigeria under this program (Fig. 1). Of the 5182 procedures, 3848 (74.4%) were by minilaparotomy under local anesthesia; 312 (6%) by laparoscopic approach and 1022 (19.7%) by ‘others’ (which includes routine laparotomy sterilization, sterilization during cesarean sections and repair of ruptured uterus). In 1989 a rise occurred in laparoscopic sterilization. This was due to the use of laparoscopic technique in one of the zonal centers - University College Hospital (UCH) that was using laparoscopic steriliza-
Minilaparotomy female sterilization in Nigeria
113
5000 4500
Female Sterilization by Approach in Nigeria, 1986-l 989
4000 3500 3000 n 2500 2000 1500 1000 500 0 1986 0
1987 Laparascopic
1988
??MULA
Others
Total
1989 0
Total
Fig. 1. Female sterilization by approach in Nigeria, 1986-1989.
tion under local anesthesia for teaching residents. However, ML/LA was still the predominant approach in other institutions. JUTH data (Table 1) indicated that the dominant age of acceptors at sterilization was the 35-39 group (42.6%); over 90% of clients were 30 years or older. It is evident that surgical sterilization is also adopted at the relatively young age of 30-34, which accounted for Table 1. Age and marital status of sterilization acceptors at JUTH, 1989. Age
19 or less 20-24 25-29 30-34 35-39 over 40 Total
No. of patients
W)
about 28% of acceptors. Sterilization acceptance falls after 40 years of age. The majority of the acceptors (97.9%) were married. Table 2 shows that remarkably, most females accepted sterilization after having 6 or more children (85.1%). It is worth noting that 115 acceptors (8 1.6”/) adopted sterilization after having at least 2 sons. (One client accepted surgical contraception voluntarily without Table 2. 1989.
Number of living children at sterilization, JUTH,
No. of children
No. of acceptor
1 son
>2 sons
0
-
1 2 12 39 60 27
0.7 1.4 8.5 27.6 42.6 19.2
1 2 3 4 5 6+
1 0 1 (0.7%) 2 (1.4%) 7 (5%) 10 (7.1%) 120 (85.1%)
-
141
100
Total
141
10
1 1 1 1 6
1 (0.7%) 6 (4.3%) 9 (6.4%) 115 (81.6%) 131
Article
114
Jack and Chao
any living children. She had a son and 8 daughters; but all died before she accepted sterilization.) The decision for female sterilization was usually made by both partners (41’/). In the remaining cases, the request for sterilization was made by the clients themselves and sometimes assisted by others including clients’ doctors, nurses and friends. The primary reason for adopting surgical contraception was the completion of desired family size. Of the couples studied 34.8% gave health factors as the most important reason for adopting surgical contraception. As indicated earlier, the surgical technique is minilaparotomy (ML/LA) under local anesthesia, with or without sedation. In almost all instances, the Pomeroy method is the most widely used for tubal occlusion (98.6%). In 1.4% of the procedures, the tubal occlusion was by clips. Minilap procedure requires little surgical time: in over 72% of cases, the procedure lasted less than 30 min. ML/LA has a low complication rate; there were no intraoperative complications in 98.6% of cases related to surgical procedure or the anesthetic regimen. However, two cases (1.4%) had some operative site bleeding which did not require blood transfusion. There were no deaths or serious postoperative complications in 88.6% of the cases. There were some cases of wound infection (7.9%); this was attributed to poor personal hygiene. These clients were not using clean clothes and were touching the operation site with dirty hands. The time interval between surgery and hospital discharge in over half of the cases was about 30 min. In a majority of cases (77.9%), the hospital stay was less than 60 min; only about 4% of cases stayed over 2 h after the procedure before discharge. These were acceptors who had the procedure at training sessions for ML/LA and those who had immediate post delivery surgery, thus requiring more time for post-delivery observations. Most of the clients (99.3%) gave positive answers indicating satisfaction with the sterilization procedure and a willingness to Int J Gynecol Obstet 39
recommend it to others. A solitary client (0.7%) reported some postoperative pains but she would still recommend it to others. These data were collected during the clients routine 7-day postoperative examination. Discussion Sterilization incidence is rising worldwide; it is now well established that large numbers of couples in the developing world also rely on contraceptive sterilization to regulate their fertility. Ross et al. [8] in their 1985 review of the global status of sterilization, did not list a number of countries in the Middle East and Africa including Nigeria because of scarcity of sterilization cases. However, many researchers believe that the number of sterilizations in the developing world is underreported. In many African countries including Nigeria, private physicians perform sterilizations on request which are unreported or concealed in the reporting of sterilization at interviews; thus country statistics of sterilizations are incomplete. This review shows that Nigeria follows the global trend of rising incidence of sterilization (Fig. 1). Nevertheless, there are still much resistance, cultural barriers and superstitious beliefs about surgical sterilization in Nigeria. This requires widespread public education and counseling. The greater part of the VSC program is directed towards information, education and counseling. Prior to the advent of ML/LA female surgical sterilization was a major operation involving the hazards of abdominal surgery, general anesthesia, hospitalization and convalescence. The advent of simplified surgical procedures for female sterilization has contributed to the upward trend in voluntary surgical sterilization acceptance in the developing world. In addition, female surgical sterilization is becoming more popular in Nigeria because of increased accessibility and availability of institutional facilities in the country and as a result of the government policy shift over the last 10 years. In Nigeria, the 1985 population policy which stipulates 4 children to one woman, promotes voluntary
Minilaparoromy female sterilization in Nigeria
sterilization of consenting adults as part of the national family planning program. The introduction of laparoscopic and minilaparotomy methods in the early 1980s has been instrumental in the sharp surge in female sterilization. Our data set indicated a decline in conventional laparotomy and laparoscopic procedures, with a corresponding compensatory rise in minilaparotomy approach. This is attributable to the nationwide VSC service program. The age patterns of sterilization acceptance vary greatly in the developing countries. In Bangladesh, over 65% of sterilization acceptors in 1978-1979 were not yet 30 years of age, while in Tunisia in 1977 about 85% were 30 years or older [8]. In Nigeria, our findings are similar to that of Tunisia and seem to follow the general pattern where peak prevalence is in the 35-39-year-old age group [7]. A mix of demographic, programmatic and supply/demand factors may explain this peak age concentration. The number of married couples available at this age bracket, the availability and accessibility of the VSC program and the desire for permanent contraception are the contributing factors. The World Fertility Survey indicated that about 50% of the fertile women in the developing countries in this age group do not want any more children. Voluntary sterilization as a birth control method was adopted by 34.8% of couples, considering the health effects of grand multiparity in the future. This indicates that these sterilization adopters are using surgical contraception to limit their families. The effect of the number of living children has on the decision to adopt permanent contraception is stronger than that of chronological age of the women in most developing countries. Our finding in Nigeria indicates that women with a large number of children are those who readily opt for sterilization - the peak family size is 6 or more children at sterilization. It would be appropriate to emphasize that this is not a rule or government policy in Nigeria. These are innovative women doing something no-one else near them did before. However, our finding in
115
Nigeria is in line with the general prevalence rate of parity four or more in developing countries [7]. Much emphasis is placed on having at least a son among the children. The male child preference is still dominant in most developing countries. In Nigeria, culturally, it is believed that having a male child provides a strong security in the husband family and inheritance of the family property. The desire for a living son may increase the parity before sterilization. In this series, the predominant procedure is the minilaparotomy under local anesthesia (ML/LA) with or without light sedation. This the complication minimizes procedure associated with general or regional anesthesia, which is a risk factor for female sterilization. The technique of tubal occlusion mostly utilized is the standard Pomeroy’s method. ML/LA is performed by both obstetrician/gynecologists and nonspecialized but appropriately trained physicians in modestly equipped facilities in urban and rural areas of the country. The instruments used are less expensive and simple to maintain, in comparison with the laparoscopic procedure which requires expensive, sophisticated instruments, special maintenance and a specially trained gynecological surgeon. It also requires general anesthesia backup in a well equipped theater in teaching and big urban hospitals [3]. Laparoscopic sterilization is considered to be a faster female sterilization method (51. This advantage over ML/LA is neutralized by the shorter duration of hospital stay. Minilap offers a singular advantage in the developing countries with limited technology and resources and where hospital beds are overcrowded [l]. It reduces the cost of hospital stay greatly. In the developing world, therefore, women wanting sterilization prefer Minilap to laparoscopy [4]. The long-term acceptability of any sterilization program depends on satisfied clients. Almost all the acceptors expressed complete satisfaction with the procedure, at the routine postoperative visit. It may be too early for evaluation, but to date there have been no regrets and no request for reversal. The preArticle
116
Jack and Chao
operative counseling emphasizes the permanency of the procedure and requires informed consent of every client to ensure both voluntary and long-term satisfaction. The cost-effectiveness and safety of the ML/LA procedure is obtained by the emphasis placed by the program on appropriate training and preoperative selection of acceptors. Female sterilization has already become a medically and culturally acceptable female contraceptive method in the developing world setting. The simpler the method the greater the chance of achieving its primary goal of safety and the secondary goals of accessibility, availability and economy. Its outpatient office approach has a great potential for the developing world. Acknowledgement We gratefully acknowledge Dr. A. Adetunji, Ms. M. Babawale of AVSC and Prof. Otubu for their assistance in this study.
Kessel Elton: Prospects for non-surgical female sterilization. Int J Gynecol Obstet 29: 1, 1989. 3 Letchworth AT, Kane JL, Nobel AD: Laparoscopy or Minilaparotomy for sterilization of women. Obstet Gynecol 56: 119, 1980. 4 Mumford SD, Bhiwandiwala PP, Chi IC: Laparoscopic and minilaparotomy female sterilization compared in 15,167 cases. Lancet ii: 1066, 1980. 5 Poindexter AN, et al.: Laparoscopic tubal sterilization under local anesthesia. Obstet Gynecol 75, 1990. 6 Ranveholt RT. Prospects of voluntary sterilization. In: Voluntary sterilization: A decade of achievement (eds ME Schima, I Lubell), p. 99. Association for voluntary sterilization, Inc., New York, 1980. 7 Ross JA et al: Worldwide trend in Voluntary Sterilization. Int Planning Perspect 12: 34, 1986. 8 Ross JA, Hong S, Huber DH: Voluntary sterilization. An International Fact Book. Association for Voluntary Sterilization, 1985. 9 Stepan J, Kellogg EH, Piotrow PT: Legal trends and issues in voluntary sterilization. Popul Rep (E) No. 6: 74, 1981. 10 World Federation of Health Agencies for the Advancement of Voluntary Surgical Contraception 1988; Safe and voluntary surgical contraception. 2
Address for reprints:
References 1 Femandez Dilone B: Anesthesia, asepsis and emergency procedures. 5th International Conference on Voluntary Surgical Contraception in the Dominican Republic, 1983.
Int J Gynecol Obstet 39
K.E. Jack Department of Obstetrics and Gynecology Columbia University 630 West 168th Street New York, NY 10032, USA
1~ J Gynecof Obsfet, 1992, 39: 11l-l 16 International Federation of Gynecology and Obstetrics
Female voluntary surgical under local anesthesia
contraception
via minilaparotomy
K.E. Jack” and C.R. Chaob ‘School of Public Health and bDepartment of Obstetrics and Gynecology, Columbia University, New York, NY (USA)
(Received February 13th, 1992) (Revised and accepted March 3Oth, 1992)
Abstract Objective: To examine changes in prevalence and acceptance of sterilization methods in a developing country from 1986 to 1990. Method: Data from 5182 voluntary female sterilizations performed at 52 service sites in Nigeria were retrospectively reviewed for sterilization method, anesthesia technique, demographic factors, and patient acceptance. Results: The annual number of sterilization procedures increased dramatically over this period from 688 in 1986 to 191I in 1989. Overall, 74.3% of the procedures were performed by minilaparotomy under local anesthesia (ML/LA), 6% by laparascopy/general anesthesia, and 19.7% by laparatomy/general anesthesia. ML/LA was found to be a very safe method, with a complication rate of 1.4% 98.6% of ML/LA patients expressed complete satisfaction with the procedure. Conclusion: Female sterilization increased in acceptance in Nigeria over the period 1986-1990 concomitant with the increased use of ML/LA. This approach is safe, costeffective, and appropriate for the developing world. Keywords: Surgical contraception; Minilaparotomy; Local-anesthesia; Developing world.
used method of contraception in the world, from an estimated 15 million in 1979 to over 100 million by 1985 [6,9]. Each year about 10 million women throughout the world choose to be sterilized. Sterilization prevalence is high in the developed countries, ranging from 30 to 40% in Canada, USA, and Europe; however, the incidence of voluntary sterilization in Africa is the lowest in the world - less than 1% in most African countries [8]. Nevertheless, in general, the incidence of sterilization in the developing world is rising in many countries and nowhere is it declining. Statistics on sterilization in Nigeria are sparse and detailed data of trends in voluntary female sterilization has not been previously studied. It is important from the public health standpoint to determine what factors unique to African settings might improve the acceptance of voluntary sterilization. We present service statistics of female sterilization in a nationwide voluntary surgical contraception (VSC) program between 1986 and 1990 to summarize the trends and the correlates of VSC in Nigeria. These data suggest that the route of anesthesia and surgical approach may be important determinants in female sterilization acceptance. Materials and methods
Introduction Over the past two decades, surgical sterilization has become the most frequently 0020-7292/92/$05.00 0 1992 International
Service statistics of female sterilizations from 52 service sites of a nationwide voluntary surgical contraception program supArticle
Federation of Gynecology and Obstetrics
112
Jack and Chao
ported by the Association for Voluntary Surgical Contraception (AVSC) between 1986 and 1990. For this program, Nigeria is divided into four zones. Four large teaching hospitals served as zonal centers with the additional responsibility to supervise and coordinate the other urban and rural sites in their zones. The northwest zone has 6 sites; the northeast zone (12 sites) has Jos University Teaching Hospital (JUTH) as the zonal center; the southeast zone has 9 sites and the southwest (25 sites) has University College Hospital (UCH) Ibadan, as the zonal center. AVSC requires these centers to report accurate quarterly statistics. JUTH, an active representative zonal center and service site, was visited and 141 client case records from January 1989 to December 1989 were studied to ascertain the correlates of voluntary female sterilization in Nigeria. The following variables were investigated: age of clients at sterilization, marital status, number of living children (sons and daughters), the primary reasons for sterilization and who made the decision. Other factors studied included the surgical approach employed, the type of anesthesia, the associated surgical complications, the postoperative hospital stay, the postoperative complications encountered and the client satisfaction as obtained by the client’s response to the question of whether she would recommend surgical contraception to others. The general trend of female voluntary sterilization was traced and the choice of minilaparotomy under local anasthesia vis-a-vis laparoscopic sterilization was studied. Description of minilaparotomy anesthesia (ML/LA)
under local
A detailed description of standard ML/LA procedure for the program is given elsewhere [lo]. In brief, the procedures are performed in simple ambulatory surgical theaters by obstetricians/gynecologists or nonspecialist doctors appropriately trained for ML/LA in training programs supported by AVSC. The patient is premeditated with 0.6 mg atropine intramuscularly. She is prepared and draped Int J Gynecol Obsrer 39
in the dorso-lithotomy position. With a speculum in the vagina, the cervix is grasped with a tenaculum. After adequate dilatation, a uterine manipulator is inserted to lift the uterus and manipulate the uterus to either side in order to reach the fallopian tubes. Immediately after the pelvic manipulation, the suprapubic (in cases of interval procedure) or infra umbilical tissues (in cases of immediate postpartum sterilization) are infiltrated with 1% xylocaine (lo-20 cc maximum) using a 1.5-inch 25-gauge hypodermic needle through a single puncture at the operation site. Each layer is infiltrated before incision. Usually a 2-5-cm long transverse incision is made. After the abdomen is opened, the fallopian tubes are hooked out and anesthestized with 5 cc of 1% xylocaine. Tubal occlusion is carried out usually using the Pomeroy technique of ligation and excision, but sometimes clips are applied. After tubal occlusion, the peritoneum may be closed. The skin closure is performed with interrupted nonabsorbable sutures or absorbable subcuticular sutures and covered with ordinary sterile dry dressing. The patient is then transferred to the recovery room where she is observed for vital signs until she is stable. After this period she is discharged home with mild analgesics. The patient is scheduled for a follow-up visit after 7 days. RMItS
From January 1986 through December 1989, there were a total of 5182 cases of female surgical sterilization reported to AVSC in Nigeria under this program (Fig. 1). Of the 5182 procedures, 3848 (74.4%) were by minilaparotomy under local anesthesia; 312 (6%) by laparoscopic approach and 1022 (19.7%) by ‘others’ (which includes routine laparotomy sterilization, sterilization during cesarean sections and repair of ruptured uterus). In 1989 a rise occurred in laparoscopic sterilization. This was due to the use of laparoscopic technique in one of the zonal centers - University College Hospital (UCH) that was using laparoscopic steriliza-
Minilaparotomy female sterilization in Nigeria
113
5000 4500
Female Sterilization by Approach in Nigeria, 1986-l 989
4000 3500 3000 n 2500 2000 1500 1000 500 0 1986 0
1987 Laparascopic
1988
??MULA
Others
Total
1989 0
Total
Fig. 1. Female sterilization by approach in Nigeria, 1986-1989.
tion under local anesthesia for teaching residents. However, ML/LA was still the predominant approach in other institutions. JUTH data (Table 1) indicated that the dominant age of acceptors at sterilization was the 35-39 group (42.6%); over 90% of clients were 30 years or older. It is evident that surgical sterilization is also adopted at the relatively young age of 30-34, which accounted for Table 1. Age and marital status of sterilization acceptors at JUTH, 1989. Age
19 or less 20-24 25-29 30-34 35-39 over 40 Total
No. of patients
W)
about 28% of acceptors. Sterilization acceptance falls after 40 years of age. The majority of the acceptors (97.9%) were married. Table 2 shows that remarkably, most females accepted sterilization after having 6 or more children (85.1%). It is worth noting that 115 acceptors (8 1.6”/) adopted sterilization after having at least 2 sons. (One client accepted surgical contraception voluntarily without Table 2. 1989.
Number of living children at sterilization, JUTH,
No. of children
No. of acceptor
1 son
>2 sons
0
-
1 2 12 39 60 27
0.7 1.4 8.5 27.6 42.6 19.2
1 2 3 4 5 6+
1 0 1 (0.7%) 2 (1.4%) 7 (5%) 10 (7.1%) 120 (85.1%)
-
141
100
Total
141
10
1 1 1 1 6
1 (0.7%) 6 (4.3%) 9 (6.4%) 115 (81.6%) 131
Article
114
Jack and Chao
any living children. She had a son and 8 daughters; but all died before she accepted sterilization.) The decision for female sterilization was usually made by both partners (41’/). In the remaining cases, the request for sterilization was made by the clients themselves and sometimes assisted by others including clients’ doctors, nurses and friends. The primary reason for adopting surgical contraception was the completion of desired family size. Of the couples studied 34.8% gave health factors as the most important reason for adopting surgical contraception. As indicated earlier, the surgical technique is minilaparotomy (ML/LA) under local anesthesia, with or without sedation. In almost all instances, the Pomeroy method is the most widely used for tubal occlusion (98.6%). In 1.4% of the procedures, the tubal occlusion was by clips. Minilap procedure requires little surgical time: in over 72% of cases, the procedure lasted less than 30 min. ML/LA has a low complication rate; there were no intraoperative complications in 98.6% of cases related to surgical procedure or the anesthetic regimen. However, two cases (1.4%) had some operative site bleeding which did not require blood transfusion. There were no deaths or serious postoperative complications in 88.6% of the cases. There were some cases of wound infection (7.9%); this was attributed to poor personal hygiene. These clients were not using clean clothes and were touching the operation site with dirty hands. The time interval between surgery and hospital discharge in over half of the cases was about 30 min. In a majority of cases (77.9%), the hospital stay was less than 60 min; only about 4% of cases stayed over 2 h after the procedure before discharge. These were acceptors who had the procedure at training sessions for ML/LA and those who had immediate post delivery surgery, thus requiring more time for post-delivery observations. Most of the clients (99.3%) gave positive answers indicating satisfaction with the sterilization procedure and a willingness to Int J Gynecol Obstet 39
recommend it to others. A solitary client (0.7%) reported some postoperative pains but she would still recommend it to others. These data were collected during the clients routine 7-day postoperative examination. Discussion Sterilization incidence is rising worldwide; it is now well established that large numbers of couples in the developing world also rely on contraceptive sterilization to regulate their fertility. Ross et al. [8] in their 1985 review of the global status of sterilization, did not list a number of countries in the Middle East and Africa including Nigeria because of scarcity of sterilization cases. However, many researchers believe that the number of sterilizations in the developing world is underreported. In many African countries including Nigeria, private physicians perform sterilizations on request which are unreported or concealed in the reporting of sterilization at interviews; thus country statistics of sterilizations are incomplete. This review shows that Nigeria follows the global trend of rising incidence of sterilization (Fig. 1). Nevertheless, there are still much resistance, cultural barriers and superstitious beliefs about surgical sterilization in Nigeria. This requires widespread public education and counseling. The greater part of the VSC program is directed towards information, education and counseling. Prior to the advent of ML/LA female surgical sterilization was a major operation involving the hazards of abdominal surgery, general anesthesia, hospitalization and convalescence. The advent of simplified surgical procedures for female sterilization has contributed to the upward trend in voluntary surgical sterilization acceptance in the developing world. In addition, female surgical sterilization is becoming more popular in Nigeria because of increased accessibility and availability of institutional facilities in the country and as a result of the government policy shift over the last 10 years. In Nigeria, the 1985 population policy which stipulates 4 children to one woman, promotes voluntary
Minilaparoromy female sterilization in Nigeria
sterilization of consenting adults as part of the national family planning program. The introduction of laparoscopic and minilaparotomy methods in the early 1980s has been instrumental in the sharp surge in female sterilization. Our data set indicated a decline in conventional laparotomy and laparoscopic procedures, with a corresponding compensatory rise in minilaparotomy approach. This is attributable to the nationwide VSC service program. The age patterns of sterilization acceptance vary greatly in the developing countries. In Bangladesh, over 65% of sterilization acceptors in 1978-1979 were not yet 30 years of age, while in Tunisia in 1977 about 85% were 30 years or older [8]. In Nigeria, our findings are similar to that of Tunisia and seem to follow the general pattern where peak prevalence is in the 35-39-year-old age group [7]. A mix of demographic, programmatic and supply/demand factors may explain this peak age concentration. The number of married couples available at this age bracket, the availability and accessibility of the VSC program and the desire for permanent contraception are the contributing factors. The World Fertility Survey indicated that about 50% of the fertile women in the developing countries in this age group do not want any more children. Voluntary sterilization as a birth control method was adopted by 34.8% of couples, considering the health effects of grand multiparity in the future. This indicates that these sterilization adopters are using surgical contraception to limit their families. The effect of the number of living children has on the decision to adopt permanent contraception is stronger than that of chronological age of the women in most developing countries. Our finding in Nigeria indicates that women with a large number of children are those who readily opt for sterilization - the peak family size is 6 or more children at sterilization. It would be appropriate to emphasize that this is not a rule or government policy in Nigeria. These are innovative women doing something no-one else near them did before. However, our finding in
115
Nigeria is in line with the general prevalence rate of parity four or more in developing countries [7]. Much emphasis is placed on having at least a son among the children. The male child preference is still dominant in most developing countries. In Nigeria, culturally, it is believed that having a male child provides a strong security in the husband family and inheritance of the family property. The desire for a living son may increase the parity before sterilization. In this series, the predominant procedure is the minilaparotomy under local anesthesia (ML/LA) with or without light sedation. This the complication minimizes procedure associated with general or regional anesthesia, which is a risk factor for female sterilization. The technique of tubal occlusion mostly utilized is the standard Pomeroy’s method. ML/LA is performed by both obstetrician/gynecologists and nonspecialized but appropriately trained physicians in modestly equipped facilities in urban and rural areas of the country. The instruments used are less expensive and simple to maintain, in comparison with the laparoscopic procedure which requires expensive, sophisticated instruments, special maintenance and a specially trained gynecological surgeon. It also requires general anesthesia backup in a well equipped theater in teaching and big urban hospitals [3]. Laparoscopic sterilization is considered to be a faster female sterilization method (51. This advantage over ML/LA is neutralized by the shorter duration of hospital stay. Minilap offers a singular advantage in the developing countries with limited technology and resources and where hospital beds are overcrowded [l]. It reduces the cost of hospital stay greatly. In the developing world, therefore, women wanting sterilization prefer Minilap to laparoscopy [4]. The long-term acceptability of any sterilization program depends on satisfied clients. Almost all the acceptors expressed complete satisfaction with the procedure, at the routine postoperative visit. It may be too early for evaluation, but to date there have been no regrets and no request for reversal. The preArticle
116
Jack and Chao
operative counseling emphasizes the permanency of the procedure and requires informed consent of every client to ensure both voluntary and long-term satisfaction. The cost-effectiveness and safety of the ML/LA procedure is obtained by the emphasis placed by the program on appropriate training and preoperative selection of acceptors. Female sterilization has already become a medically and culturally acceptable female contraceptive method in the developing world setting. The simpler the method the greater the chance of achieving its primary goal of safety and the secondary goals of accessibility, availability and economy. Its outpatient office approach has a great potential for the developing world. Acknowledgement We gratefully acknowledge Dr. A. Adetunji, Ms. M. Babawale of AVSC and Prof. Otubu for their assistance in this study.
Kessel Elton: Prospects for non-surgical female sterilization. Int J Gynecol Obstet 29: 1, 1989. 3 Letchworth AT, Kane JL, Nobel AD: Laparoscopy or Minilaparotomy for sterilization of women. Obstet Gynecol 56: 119, 1980. 4 Mumford SD, Bhiwandiwala PP, Chi IC: Laparoscopic and minilaparotomy female sterilization compared in 15,167 cases. Lancet ii: 1066, 1980. 5 Poindexter AN, et al.: Laparoscopic tubal sterilization under local anesthesia. Obstet Gynecol 75, 1990. 6 Ranveholt RT. Prospects of voluntary sterilization. In: Voluntary sterilization: A decade of achievement (eds ME Schima, I Lubell), p. 99. Association for voluntary sterilization, Inc., New York, 1980. 7 Ross JA et al: Worldwide trend in Voluntary Sterilization. Int Planning Perspect 12: 34, 1986. 8 Ross JA, Hong S, Huber DH: Voluntary sterilization. An International Fact Book. Association for Voluntary Sterilization, 1985. 9 Stepan J, Kellogg EH, Piotrow PT: Legal trends and issues in voluntary sterilization. Popul Rep (E) No. 6: 74, 1981. 10 World Federation of Health Agencies for the Advancement of Voluntary Surgical Contraception 1988; Safe and voluntary surgical contraception. 2
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References 1 Femandez Dilone B: Anesthesia, asepsis and emergency procedures. 5th International Conference on Voluntary Surgical Contraception in the Dominican Republic, 1983.
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K.E. Jack Department of Obstetrics and Gynecology Columbia University 630 West 168th Street New York, NY 10032, USA